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UNIT 5 ANXIETY, DEATH AND DYING
It is also an emotioncharacterised by an unpleasant state of inner turmoil, often accompanied by nervous behavior, such as pacing back and forth, somatic complaints and rumination. It is the subjectively unpleasant feelings of dread over anticipated events, such as the feeling of imminent death. Anxiety is not the same as fear, which is a response to a real or perceived immediate threat; whereas anxiety is the expectation of future threat. Anxiety is a feeling of fear, worry, and uneasiness, usually generalized and unfocused as an overreaction to a situation that is only subjectively seen as menacing. It is often accompanied by muscular tension, restlessness, fatigue and problems in concentration. Anxiety can be appropriate, but when experienced regularly the individual may suffer from an anxiety disorder.
People facing anxiety may withdraw from situations which have provoked anxiety in the past. There are different types of anxiety.
Existential anxiety can occur when a person faces angst, an existential crisis, or nihilistic feelings. People can also face test anxiety, mathematical anxiety, stage fright or somatic anxiety. Another type of anxiety, stranger anxiety and social anxiety are caused when people are apprehensive around strangers or other people in general. Anxiety can be either a short term 'state' or a long term "trait". Anxiety disorders are a group of mental disorderscharacterised by feelings of anxiety and fear, whereas trait anxiety is a worry about future events, close to the concept of neuroticism. Anxiety disorders are partly genetic but may also be due to drug use including alcohol and caffeine, as well as withdrawal from certain drugs. They often occur with other mental disorders, particularly major depressive disorder, bipolar disorder, certain personality disorders, and eating disorders. Common treatment options include lifestyle changes, therapy, and medications.
3.1.1 Descriptions
Anxiety is distinguished from fear, which is an appropriate cognitive and emotional response to a perceived threat and is related to the specific behaviors of fight-or-flight responses, defensive behavior or escape. It occurs in situations only perceived as uncontrollable or unavoidable, but not realistically so. David Barlow defines anxiety as "a future-oriented mood state in which one is ready or prepared to attempt to cope with upcoming negative events," and that it is a distinction between future and present dangers which divides anxiety and fear.
Another description of anxiety is agony, dread, terror, or even apprehension. In positive psychology, anxiety is described as the mental state that results from a difficult challenge for which the subject has insufficient coping skills.
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Fear and anxiety can be differentiated in four domains: duration of emotional experience, temporal focus, specificity of the threat, and motivated direction. Fear is defined as short lived, present focused, geared towards a specific threat, and facilitating escape from threat;
while anxiety is defined as long acting, future focused, broadly focused towards a diffuse threat, and promoting excessive caution while approaching a potential threat and interferes with constructive coping.
Anxiety can be experienced with long, drawn out daily symptoms that reduce quality of life, known as chronic (or generalised) anxiety, or it can be experienced in short spurts with sporadic, stressful panic attacks, known as acute anxiety.
Symptoms of anxiety can range in number, intensity, and frequency, depending on the person. While almost everyone has experienced anxiety at some point in their lives, most do not develop long-term problems with anxiety. The behavioral effects of anxiety may include withdrawal from situations which have provoked anxiety in the past.
Anxiety can also be experienced in ways which include changes in sleeping patterns, nervous habits, and increased motor tension like foot tapping.The emotional effects of anxiety may include "feelings of apprehension or dread, trouble concentrating, feeling tense or jumpy, anticipating the worst, irritability, restlessness, watching (and waiting) for signs (and occurrences) of danger, and, feeling like your mind's gone blank" as well as "nightmares/bad dreams, obsessions about sensations, , and feeling like everything is scary."
The cognitive effects of anxiety may include thoughts about suspected dangers, such as fear of dying. "You may ... fear that the chest pains are a deadly heart attack or that the shooting pains in your head are the result of a tumor or aneurysm. You feel an intense fear when you think of dying, or you may think of it more often than normal, or can't get it out of your mind."As has been explained above, anxiety alerts a person to impending or perceived danger facilitated through the sympathetic nervous system. Anxiety maintains all potential resources, emotional and physical, in readiness for emergencies. Anxiety is related to each individual’s perception of the environment around him or her. It is based upon a person’s psychological processes and personal history. The factors that lead to anxiety can be divided into two general categories:
normal and detrimental.
3.1.2 Normal Anxiety Levels
A normal level of anxiety varies from individual to individual. It acts as a warning system to put us on guard, so we won’t be overwhelmed by a sudden stimulation or immobilized in a critical situation. Normal anxiety may be considered adaptive, because it has evolved to help us cope with
stressors by focusing our attention. It helps us increase our tolerance for stress by developing coping and/ or defense mechanisms.
This process is evident in emergency medical services. The first emergency response that an emergency medical team or paramedic makes is a very stressful event. The person experiences a high pulse rate, dilated pupils, poorly organised thought process, and a feeling of tension. However, over time the body adapts to stresseach response more and more routine. However, as long as the emergency medical team (EMT) or paramedic is, on call, for emergency response, his or her level of anxiety never returns to a non-work state. Keeping anxiety at an, on-alert, is a coping mechanism. Because it is impossible to predict and prepare for the next problem, anxiety helps the paramedic maintain a level of readiness.
3.1.3 Detrimental Anxiety Levels
Although many reactions to anxiety and stress are positive, there are also detrimental ones .Detrimental reactions include the failure of anxiety to stimulate the appropriate coping mechanisms. Conversely, an increase in anxiety that is disproportionate to the actual danger would also be detrimental. These reactions may interfere with a rational thought process, disrupt performance, or cause physical problems.
Symptoms of anxiety include:
(i) Heart palpitations
(ii) Difficult or rapid breathing (iii) Dry mouth
(iv) Chest tightness or pain
(v) Anorexia, nausea, vomiting, abdominal cramps, flatulence, or the classic butterflies in the stomach.
(vi) Flushing, diaphoresis or fluctuation in the body temperature (vii) Urgency or frequency of urination
(viii) Dysmenorrhea, or decreased sexual drive or performance (ix) Aching muscles or joints
(x) Backache or headache.
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Effects that are not felt include:
(i) Increased blood pressure and heart rate (ii) Blood shunting to muscles
(iii) Increased blood glucose levels
(iv) Increased catecholamine production by the adrenal glands (v) Reduced peristalsis in the digestive tract
(vi) Pupillary dilation.
People react differently to stress. The patient and family may react with anger, guilt, or indecisiveness. As a paramedic, you may react with impatience, fear, or anger. It is important to remember that the patient and family are not as adept at dealing with stress as you the professional.
Because of indecisiveness, the patient and family members should not be given too many alternatives. Despite your emotions, you must maintain a professional attitude and non- judgmental. Common treatment options include lifestyle changes, therapy, and medications.
Medications are typically recommended only if other measures are not effective. Early warning signs of anxiety must be recognised.
3.2 Death and Dying
Death is the end of life while dying is the process of approaching death, including the choices and actions involved in that process , it can also be defined as the cessation of all vital functions of the body including the heartbeat, brain activity(including the brain stem), and breathing.
Phenomena which commonly bring about death include biological aging (senescence), predation, malnutrition, disease, suicide, homicide, starvation, dehydration, and accidents or trauma resulting in terminal injury. Bodies of living organisms begin to decompose shortly after death. Death has commonly been considered a sad or unpleasant occasion, due to the termination of bonds with or affection for the being that has died, or having fear of death, necrophobia, anxiety, sorrow, grief, emotional pain, depression, sympathy, compassion, solitude, or saudade.
3.2.1 Signs of Biological Death
Signs of death or strong indications that a warm-blooded animal is no longer alive are:
• Cessation of breathing
• Cardiac arrest (no pulse)
• Pallor mortis, paleness which happens in the 15–120 minutes after death
• Livor mortis, a settling of the blood in the lower (dependent) portion of the body
• Algor mortis, the reduction in body temperature following death.
This is generally a steady decline until matching ambient temperature
• Rigor mortis, the limbs of the corpse become stiff (Latin rigor) and difficult to move or manipulate
• Decomposition, the reduction into simpler forms of matter, accompanied by a strong, unpleasant odor.
3.2.2 Causes of Death
The leading cause of human death in developing countries is infectious disease. The leading causes in developed countries are atherosclerosis (heart disease and stroke), cancer, and other diseases related to obesity and aging.
By extremely wide margin, the largest unifying cause of death in the developed world is biological aging, leading to various complications known as aging-associated diseases. These conditions cause loss of homeostasis, leading to cardiac arrest, causing loss of oxygen and nutrient supply, causing irreversible deterioration of the brain and other tissues. Of the roughly 150,000 people who die each day across the globe, about two thirds die of age-related causes. In industrialized nations, the proportion is much higher, approaching 90%.With improved medical capability, dying has become a condition to be managed. Home deaths, once commonplace, are now rare in the developed world.
• In developing nations, inferior sanitary conditions and lack of access to modern medical technology makes death from infectious diseases more common than in developed countries. One such disease is tuberculosis, a bacterial disease which killed 1.7M people in 2004. Malaria causes about 400–900M cases of fever and 1–3M deaths annually. AIDS death toll in Africa may reach 90–100M by 2025.
• According to Jean Ziegler (United Nations Special Reporter on the Right to Food, 2000—Mar 2008), mortality due to malnutrition accounted for 58% of the total mortality rate in 2006. Ziegler says worldwide approximately 62M people died from all causes and of those deaths more than 36M died of hunger or diseases due to deficiencies in micronutrients.
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• Tobacco smoking killed 100 million people worldwide in the 20th century and could kill 1 billion people around the world in the 21st century, a WHO Report warned.
• Many leading developed world causes of death can be postponed by diet and physical activity, but the accelerating incidence of disease with age still imposes limits on human longevity. The evolutionary cause of aging is, at best, only just beginning to be understood. It has been suggested that direct intervention in the aging process may now be the most effective intervention against major causes of death.
• In 2012, suicide overtook car crashes for leading causes of human injury deaths in America, followed by poisoning, falls and murder. Causes of death are different in different parts of the world. In high-income and middle income countries nearly half up to more than two thirds of all people live beyond the age of 70 and predominantly die of chronic diseases. In low-income countries, where less than one in five of all people reach the age of 70, and more than a third of all deaths are among children under 15, people predominantly die of infectious diseases.
Autopsy
An autopsy, also known as a postmortem examination or an obduction, is a medical procedure that consists of a thorough examination of a human corpse to determine the cause and manner of a person's death and to evaluate any disease or injury that may be present. It is usually performed by a specialisedmedical doctor called a pathologist.Autopsies are either performed for legal or medical purposes. A forensic autopsy is carried out when the cause of death may be a criminal matter, while a clinical or academic autopsy is performed to find the medical cause of death and is used in cases of unknown or uncertain death, or for research purposes. Autopsies can be further classified into cases where external examination suffices, and those where the body is dissected and an internal examination is conducted. Permission from next of kin may be required for internal autopsy in some cases. Once an internal autopsy is complete the body is generally reconstituted by sewing it back together.
Autopsy is important in a medical environment and may shed light on mistakes and help improve practices.
• A "necropsy" is an older term for a postmortem examination, unregulated, and not always a medical procedure. In modern times the term is more often used in the postmortem examination of the corpses of animals.
3.2.3 Grief Process
The family of a dying patient, as well as the patient, goes through a grief process initially. The grief process has several identifiable stages;
(i) Denial and Isolation; this stage is used by most dying patients. It is healthy and acts as a mental buffer between the shock of dying and dealing with it. It happens throughout the illness. It is temporary stage, often giving way to acceptance.
(ii) Anger: In the anger phase, the patient and the family ask, Why me?
People are angered at the loss and may project their anger to anything and anyone. It is important to remember that this anger has little to do with the people or things present; they are often simply, targets. The anger can be difficult for you to deal with. Try not to take the patients or the family’s anger personally. Be tolerant and be don’t be afraid of anger. Don’t become defensive. Listen to the patient and family.
(iii) Bargaining: Bargaining is a defensive mechanism use by the dying patient to formulate some sort of agreement, which in the patient‘smind, postpones the inevitable.
(iv) Depression: Depression is common and expected. It is a normal response to the greatest loss. In reactive depression, the dying patient reacts to the need of a life situation. For example, who will care for the children or take care of the funeral arrangements? There is also preparatory depression. In this state, the patient is often silent and reassurance is not meaningful.
(v) Acceptance: Acceptance may not be a happy stage. At this point, the patient is without fear and despair. He or she is devoid of feelings. The patient becomes less involved with people as he or she prepares face death alone. At this stage, the family needs help, understanding and support more than the patient.
It is important to recognise the needs of individuals when dealing with the dead or dying. The dying patient needs dignity and respect, sharing, communication, hope, privacy, and control. The family has needs, too.
They often go through a grief process similar to the patient’s. They may need to express their feelings of rage, anger and despair. In addition they need to reduce their feelings of guilt. You may also go through some grief stages. This coping requires a lot of energy to cover feelings. It should be followed by adequate time for reflection and discussion.
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3.2.4 Treatment/Management of the Dead or Dying Patient
How you react to death and the dying patient reflects your own thoughts and beliefs. It is natural to feel uncomfortable. Don’t bring up the subject of death. Let the patient do so. Don’t falsely reassure the patient or the family. Do not be afraid to tell the patient that he or she is dying, if asked. Use non-verbal communications, such as a gentle tone of voice, appropriate facial expression, and a reassuring touch .If the patient is already dead, the family becomes, the patient. Comfort the family with kind deeds, such as calling neighbours , family members, or a minister . The family needs to hear the word dead.Avoid, Euphemisms like expired, passed away, or moved on. Always refer to the deceased patient by their name. Recognise that the family will cope with death in much the same manner as they deal with everyday stresses. Only recently has there been concerted public effort to address the care of the dying in an effort to improve their comfort and lessen their alienation from those still living. Hospice care represents one of the greatest advances made in this direction. There has also been a liberalization of the use of narcotics and other drugs for symptomatic relief and improvement in the quality of life for the dying.
Living will
One of the most difficult issues surrounding death in the era of technology is that there is now a choice, not of the event itself, but of its timing. When to die, and more often, when to let a loved one die, is coming within people's power to determine. This is both a blessing and a dilemma. Insofar as the decision can be made ahead of time, a living will is an attempt to address this dilemma. By outlining the conditions under which one would rather be allowed to die, a person can contribute significantly to that final decision, even if not competent to do so at the time of actual death. The problem is that there are uncertainties surrounding every severely ill person. Each instance presents a greater or lesser chance of survival. The chance is often greater than zero. The best living will follows an intimate discussion with decision makers covering the many possible scenarios surrounding the end of life. This discussion is difficult, for few people like to contemplate their own demise. However, the benefits of a living will are substantial, both to physicians and to loved ones who are faced with making final decisions.
Most states have passed living will laws, honoring instructions on
artificial life support that were made while a person was still mentally competent.
Euthanasia
Another issue that has received much attention is assisted suicide (euthanasia). In 1997, the State of Oregon placed the issue on the ballot, amid much consternation and dispute. Perhaps the main reason euthanasia has become front page news is because Dr. Jack Kevorkian, a pathologist from Michigan, is one of its most vocal advocates. The issue highlights the many new problems generated by increasing ability to intervene effectively in the final moments of life and unnaturally prolong the process of dying. The public appearance of euthanasia has also stimulated discussion about more compassionate care of the dying.
Prevention
Autopsy after death is a way to precisely determine a cause of death.
The word autopsy is derived from Greek meaning to see with one's own eyes. A pathologist extensively examines a body and submits a detailed report to an attending physician. Although an autopsy can do nothing for an individual after death, it can benefit the family and, in some cases, medical science. Hereditary disorders and disease may be found. This knowledge could be used to prevent illness in other family members.
Information culled from an autopsy can be used to further medical research. The link between smoking and lung cancer was confirmed from data gathered through autopsy. Early information about AIDS was also compiled through autopsy reports.
4.0 CONCLUSION
Anxiety,Death and Dying are all part of emergency medical services. It is important to develop an appropriate personal attitude about them. As public health practioner you must learn to adapt and deal with these situations positively.
5.0 SUMMARY
Anxiety, death and dying are all part of emergency situations. This unit has focused on descriptions of Anxiety, Death and Dying, their signs, management and preventions. You should now be able to explain them in your own words.
6.0 TUTOR-MARKED ASSIGNMENT
(I) Describe the normal anxiety levels. What are its merits?